Addressing Multiple Problems in the Family Practice Office Visit

In combination with other reports,²⁹ these data should caution the use of billing records as an indicator of the content of the visit. These data indicate that the billing record generally underrepresents the number of problems addressed during the visit. The lack of concordance between what was observed and what was billed may have several explanations. Underrecording on the billing sheet may be due to the lack of an adequate way to code some problems addressed. Some physicians may approach the completion of the billing sheet by documenting just enough to justify the time spent. Also, the mode of recording the billing (forms or computer programs) may limit the number of problems that can be recorded per visit. Nonconcordance may have also occurred if the physician made decisions about management of ongoing illnesses that were not overtly apparent to the observer.

Limitations

The generalizability of our findings is limited by the modest-sized convenience sample of physicians observed. The higher no-show rate by younger patients may have increased the number of problems seen per visit, since older patients tend to have more problems. However, the patient visits included in our study were randomly selected from all adult patient visits during the 6-week data collection period and were similar in sex to the few patients who were not observed and are likely to be reflective of the patients presenting for care. Although not assessed directly, inter-rater reliability among the 7 students was maximized through the use of videotaped patient encounters for practicing completing the data collection form and for calibrating the observers before data collection in the field.

Conclusions

Prioritizing and delivering a diverse array of services within a relationship context is a hallmark of family practice. Our data suggest that addressing multiple problems during a single outpatient visit is one important mechanism family physicians use to provide comprehensive care. The value of addressing multiple problems per visit in terms of patient satisfaction, cost, and quality of care deserves further investigation.

Acknowledgments

We are grateful to Catharine Symmonds, Catherine Bettcher, Elizabeth Welsh, Tracy Lemonovich, Robin Baines, and Sarah Younkin who contributed to the study design and data collection phase and without whose participation our study would not have been possible. William R. Phillips, MD, MPH, and Kurt C. Stange, MD, PhD, provided valuable suggestions on an earlier draft of this paper.

Related Resources

• Center for Research in Family Practice and Primary Care https://mediswww.cwru.edu/dept/CRFPPC.
• American Academy of Family Practice policy studies in family practice and primary care https://www.aafppolicy.org